At what age should a Pap smear be performed in a 19-year-old?

Cervical Cancer Screening in a 19-Year-Old

Pap smear screening should not be performed in a 19-year-old patient, as current guidelines recommend beginning cervical cancer screening at age 21 regardless of sexual history or age of sexual debut.

Rationale for Starting Screening at Age 21

The recommendation to begin screening at age 21 is based on several important factors:

• Cervical cancer is extremely rare in women under 21 years of age 1
• The incidence rate of invasive cervical cancer is approximately 0/100,000/year for ages 15-19 years 2
• HPV infections in adolescents and young women are often transient and clear spontaneously without intervention 1
• Early screening can lead to unnecessary procedures for lesions that would likely regress on their own 2
• There is concern about the potential harm of treating cervical lesions in young women, including increased risk of premature births following excisional procedures 2

Current Guideline Recommendations

Multiple authoritative organizations have aligned on this recommendation:

• The U.S. Preventive Services Task Force (USPSTF) recommends starting at age 21 1
• The American Cancer Society (ACS) recommends starting at age 21 1, 2
• The American College of Obstetricians and Gynecologists (ACOG) recommends starting at age 21 1, 2
• The American College of Physicians also recommends starting at age 21 1

Screening Schedule After Age 21

When the patient reaches age 21, the recommended screening schedule is:

• Ages 21-29: Cytology (Pap smear) alone every 3 years 1, 2
• Ages 30-65: Preferred approach is HPV and cytology co-testing every 5 years, or alternatively cytology alone every 3 years 1, 2

Common Pitfalls to Avoid

1. Premature screening: Despite guidelines, a significant proportion of women under 21 continue to receive Pap tests unnecessarily. About 25.1% of women receive a Pap test before age 21 3.

2. Overscreening: Many providers continue to perform annual screening despite evidence showing little advantage of annual versus biennial screening 2. Studies show that 55% of American women undergo annual Pap screening despite recommendations for less frequent intervals 4.

3. HPV testing in young women: HPV testing should not be used for screening women in the 21-29 age group 1. Current FDA-approved HPV tests are not recommended for women aged <20 years for screening or management of abnormal Pap tests 2.

4. Confusion about sexual activity: The recommendation to begin screening at age 21 applies regardless of sexual history or age of sexual debut 1. The previous recommendation to begin screening "approximately" three years after the onset of sexual intercourse has been replaced with a clear age-based guideline 2.

Special Considerations

• Women with special risk factors (such as immunocompromised status, HIV infection) may require different screening protocols 1
• HIV-infected young women should follow the US Public Health System Guidelines, obtaining a Pap test twice in the first year after diagnosis of HIV infection and, if results are normal, annually thereafter 2

Conclusion

For a 19-year-old patient, the evidence-based recommendation is to wait until age 21 to begin cervical cancer screening with a Pap test, regardless of sexual history. This approach balances the extremely low risk of cervical cancer in this age group against the potential harms of unnecessary procedures and overtreatment.